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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI_:.OFFICE USE: 1601 E. Hazelton .Ave. , .Stockton, Calif. <br /> ' Telephone: (209) 466--6781 <br /> APPLICATION FOR WELLiCONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS,PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued ,`-,177 <br /> (Complete. In; Triplicate) <br /> Application is hereby made to the San Joaquin .Local. tlealth District for a permit to construct <br /> and/or install the work. herein described. . This application is 'made in compliance with San Joaquin <br /> County Ordinance 'No. 1862 and the 'Rules .and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION'. g &40 Zd/t CENSUS TRACT <br /> Owner's Name S'j v f( .#S Phone <br /> Address' d Ste. Tri - � ~ City ._ay eX, �. .-. <br /> Contractor's Name Q S,< _AQZ..ell Licensed Phones3��s' <br /> TYPE OF WORK (Check) : NEW WELL IA- ' DEEPEN/ / RECONDITION_/_/ DESTRUCTION. /^] <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC �TANK SEWER LINES Zai PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN (PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation /I— 11�l <br /> Domestic/private j Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing \ , <br /> Irrigation Gravel Pack Depth of Grout Seal v <br /> Cathodic Protection A�, Rotary Type of Grout _��` t.w Y <br /> Disposal -Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: —Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: n <br /> / State`Work Done , <br /> PUMP �REPAIR: . .. / / State-Work Done-_._ <br /> DESTRUCTION OF WELL: -Well Diameter Approximate Depth <br /> Describe Material. and..Procedure <br /> I hereby agree to comply with` a11 laws and regulations of the San Joaquin Local Health District <br />'rand the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />` after completion of my work£on a new well; I will;furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the ,well and notify them before putting the well in use.. . The above <br /> information is true to the-best of my knowlecdge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL�TNSPECTION_ r y <br /> SIGNED I TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SI ) <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> FOR <br /> e <br /> APPLICATION. ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA II GROUT INSPECTION P SE II/FINAL INSPECTION <br /> INSPECTION B DATE a - u1-17 INSPECTION BY DATE <br /> E H 1426 Rev. - I-74 2M .e" <br />